Skip to main content
Top
Published in: CardioVascular and Interventional Radiology 2/2013

Open Access 01-04-2013 | Clinical Investigation

A Checklist to Improve Patient Safety in Interventional Radiology

Authors: Inge C. J. Koetser, Eefje N. de Vries, Otto M. van Delden, Susanne M. Smorenburg, Marja A. Boermeester, Krijn P. van Lienden

Published in: CardioVascular and Interventional Radiology | Issue 2/2013

Login to get access

Abstract

Purpose

To develop a specific RADiological Patient Safety System (RADPASS) checklist for interventional radiology and to assess the effect of this checklist on health care processes of radiological interventions.

Materials and Methods

On the basis of available literature and expert opinion, a prototype checklist was developed. The checklist was adapted on the basis of observation of daily practice in a tertiary referral centre and evaluation by users. To assess the effect of RADPASS, in a series of radiological interventions, all deviations from optimal care were registered before and after implementation of the checklist. In addition, the checklist and its use were evaluated by interviewing all users.

Results

The RADPASS checklist has two parts: A (Planning and Preparation) and B (Procedure). The latter part comprises checks just before starting a procedure (B1) and checks concerning the postprocedural care immediately after completion of the procedure (B2). Two cohorts of, respectively, 94 and 101 radiological interventions were observed; the mean percentage of deviations of the optimal process per intervention decreased from 24 % before implementation to 5 % after implementation (p < 0.001). Postponements and cancellations of interventions decreased from 10 % before implementation to 0 % after implementation. Most users agreed that the checklist was user-friendly and increased patient safety awareness and efficiency.

Conclusion

The first validated patient safety checklist for interventional radiology was developed. The use of the RADPASS checklist reduced deviations from the optimal process by three quarters and was associated with less procedure postponements.
Literature
1.
go back to reference de Vries EN, Ramrattan MA, Smorenburg SM et al (2008) The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care 17:216–223PubMedCrossRef de Vries EN, Ramrattan MA, Smorenburg SM et al (2008) The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care 17:216–223PubMedCrossRef
2.
go back to reference Christian CK, Gustafson ML, Roth EM et al (2006) A prospective study of patient safety in the operating room. Surgery 139:159–173PubMedCrossRef Christian CK, Gustafson ML, Roth EM et al (2006) A prospective study of patient safety in the operating room. Surgery 139:159–173PubMedCrossRef
3.
go back to reference Dankelman J, Grimbergen CA (2005) Systems approach to reduce errors in surgery. Surg Endosc 19:1017–1021PubMedCrossRef Dankelman J, Grimbergen CA (2005) Systems approach to reduce errors in surgery. Surg Endosc 19:1017–1021PubMedCrossRef
4.
go back to reference Angle JF, Nemcek AA Jr, Cohen AM et al (2008) Quality improvement guidelines for preventing wrong site, wrong procedure, and wrong person errors: application of the joint commission “Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery” to the practice of interventional radiology. J Vasc Interv Radiol 19:1145–1151PubMedCrossRef Angle JF, Nemcek AA Jr, Cohen AM et al (2008) Quality improvement guidelines for preventing wrong site, wrong procedure, and wrong person errors: application of the joint commission “Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery” to the practice of interventional radiology. J Vasc Interv Radiol 19:1145–1151PubMedCrossRef
5.
go back to reference Duncan JR (2008) Strategies for improving safety and quality in interventional radiology. J Vasc Interv Radiol 19:3–7PubMedCrossRef Duncan JR (2008) Strategies for improving safety and quality in interventional radiology. J Vasc Interv Radiol 19:3–7PubMedCrossRef
6.
go back to reference Jacobs B, Duncan JR (2009) Improving quality and patient safety by minimizing unnecessary variation. J Vasc Interv Radiol 20:157–163PubMedCrossRef Jacobs B, Duncan JR (2009) Improving quality and patient safety by minimizing unnecessary variation. J Vasc Interv Radiol 20:157–163PubMedCrossRef
11.
go back to reference Haynes AB, Weiser TG, Berry WR et al (2009) A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 360:491–499PubMedCrossRef Haynes AB, Weiser TG, Berry WR et al (2009) A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 360:491–499PubMedCrossRef
12.
go back to reference de Vries EN, Prins HA, Crolla RMPH et al (2010) Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med 363:1928–1937PubMedCrossRef de Vries EN, Prins HA, Crolla RMPH et al (2010) Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med 363:1928–1937PubMedCrossRef
14.
go back to reference Lee MJ, Fanelli F, Haage P et al (2012) Patient safety in interventional radiology: a CIRSE IR checklist. Cardiovasc Intervent Radiol 35:244–246PubMedCrossRef Lee MJ, Fanelli F, Haage P et al (2012) Patient safety in interventional radiology: a CIRSE IR checklist. Cardiovasc Intervent Radiol 35:244–246PubMedCrossRef
15.
go back to reference de Vries EN, Hollmann MW, Smorenburg SM et al (2009) Development and validation of the SURgical PAtient Safety System (SURPASS) checklist. Qual Saf Health Care 18:121–126PubMedCrossRef de Vries EN, Hollmann MW, Smorenburg SM et al (2009) Development and validation of the SURgical PAtient Safety System (SURPASS) checklist. Qual Saf Health Care 18:121–126PubMedCrossRef
16.
17.
go back to reference Cardella JF, Kundu S, Miller DL et al (2009) Society of Interventional Radiology clinical practice guidelines. J Vasc Interv Radiol 20(7 Suppl):S189–S191PubMedCrossRef Cardella JF, Kundu S, Miller DL et al (2009) Society of Interventional Radiology clinical practice guidelines. J Vasc Interv Radiol 20(7 Suppl):S189–S191PubMedCrossRef
18.
go back to reference Knight F, Galvin R, Davoren M et al (2006) The evolution of universal protocol in interventional radiology. J Radiol Nurs 25:106–115CrossRef Knight F, Galvin R, Davoren M et al (2006) The evolution of universal protocol in interventional radiology. J Radiol Nurs 25:106–115CrossRef
19.
go back to reference Sridhar S, Duncan JR (2008) Strategies for choosing process improvement projects. J Vasc Interv Radiol 19:471–477PubMedCrossRef Sridhar S, Duncan JR (2008) Strategies for choosing process improvement projects. J Vasc Interv Radiol 19:471–477PubMedCrossRef
21.
go back to reference Tuong B, Shnitzer Z, Pehora C et al (2009) The experience of conducting mortality and morbidity reviews in a pediatric interventional radiology service: a retrospective study. J Vasc Interv Radiol 20:77–86PubMedCrossRef Tuong B, Shnitzer Z, Pehora C et al (2009) The experience of conducting mortality and morbidity reviews in a pediatric interventional radiology service: a retrospective study. J Vasc Interv Radiol 20:77–86PubMedCrossRef
22.
go back to reference Stecker MS, McNamara D (2007) IR safety rounds: forgotten dialysis catheter caps. J Vasc Interv Radiol 18:1479–1480PubMedCrossRef Stecker MS, McNamara D (2007) IR safety rounds: forgotten dialysis catheter caps. J Vasc Interv Radiol 18:1479–1480PubMedCrossRef
23.
go back to reference Brown C, Hofer T, Johal A et al (2008) An epistemology of patient safety research: a framework for study design and interpretation. Part 4 One size does not fit all. Qual Saf Health Care 17:178–181PubMedCrossRef Brown C, Hofer T, Johal A et al (2008) An epistemology of patient safety research: a framework for study design and interpretation. Part 4 One size does not fit all. Qual Saf Health Care 17:178–181PubMedCrossRef
24.
go back to reference Anonymous (2008) The Joint Commission announces the 2009 national patient safety goals and requirements Jt Comm Perspect 28(1):11–15 Anonymous (2008) The Joint Commission announces the 2009 national patient safety goals and requirements Jt Comm Perspect 28(1):11–15
Metadata
Title
A Checklist to Improve Patient Safety in Interventional Radiology
Authors
Inge C. J. Koetser
Eefje N. de Vries
Otto M. van Delden
Susanne M. Smorenburg
Marja A. Boermeester
Krijn P. van Lienden
Publication date
01-04-2013
Publisher
Springer-Verlag
Published in
CardioVascular and Interventional Radiology / Issue 2/2013
Print ISSN: 0174-1551
Electronic ISSN: 1432-086X
DOI
https://doi.org/10.1007/s00270-012-0395-z

Other articles of this Issue 2/2013

CardioVascular and Interventional Radiology 2/2013 Go to the issue